Practice of Axilla Surgery

Transcription

1 Summer School of Breast Disease 2016 Practice of Axilla Surgery Axillary Lymph Node Dissection & Sentinel Lymph Node Biopsy 연세의대외과 박세호

2 Contents Anatomy of the axilla Axillary lymph node dissection (ALND) Sentinel lymph node biopsy (SLNB) ASCO guideline and updates

3 Borders of the axilla - like a pyramid - Apex (axillary inlet) : lateral border of the first rib, superior border of scapula, & posterior border of clavicle Lateral wall : intertubecular groove of humerus. Medial wall : serratus anterior & thoracic wall (ribs, intercostal m.) Anterior wall : pectoralis major, pectoralis minor, & subclavius m. Posterior wall : subscapularis, teres major, & latissimus dorsi Base : skin

4 Lymph nodes

5 Motor nerves Atrophy and shortening of pectoral muscle Impaired arm abduction Winged scapula Shoulder apraxia

6 Sensory nerves High: skin sensation of upper-medial arm Low: axilla skin Intercostobrachial nerve

7 Axillary Lymph Node Dissection

8 Meta-Analysis: ALND versus None 6 trials 3000 pts 5% Improvement Orr RK, Ann Surg Oncol, 1998

9 The Impact of ALND Clearance of Regional Disease Staging - Prognostic factor - Adjuvant therapy Improve chance of cure Survival benefit Kim et al. J Breast Cancer 2014;17(2):

10 Indication for ALND 감시림프절생검술에서전이를보이는경우 감시림프절생검의금기또는감시림프절을찾지못한경우 염증성유방암에서선행화학요법후수술시 감시림프절생검술후액와부림프절지역재발의경우 감시림프절을벗어난액와부림프절의전이의가능성이높거나확인된경우.

11 Indications for ALND in the Era of SLN Biopsy Patients outside the ACOSOG Z0011 entry criteria 1 Prior inadequate ALND Validation trials of SLN biopsy Failed SLN biopsy Clinically suspicious nodes identified at surgery T4 disease Unavailability of SLN biopsy Axillary local recurrence (ipsilateral or contralateral) in previously treated patients 1 T3, clinically positive axilla and biopsy-proven nodal metastasis, positive SLN with disease requiring mastectomy, more than 2 positive SLNs or matted axillary nodes. Disease of the Breast 5 th ed.

12 Contraindication for ALND 임상적으로임파절전이가없을때감시림프절생검술상음성시 Ductal carcinoma in situ / Lobular carcinoma in situ 액와부림프절의전이의가능성이낮거나음성이확인된경우.

13 Preoperative preparation Axillary shaving Pad for arm board Preventing shoulder dislocation Preventing brachial plexus tension injury Broad spectrum antibiotics IV just before surgery Short term muscle relaxant

14 Procedures of ALND (I) Identification of landmark -> pectoralis muscles, LD Opening of clavipectoral fascia Preservation of axillary vein, artery and brachial plexus Preservation of medial / lateral pectoral nerves Ligation of braches of axillary vein

15 Procedures of ALND (II) Mobilization of axillary fat pad Identification of intercostobrachial nerve Identification of motor nerves (long thoracic nerve & thoracodorsal neurovascular bundle)

16 Extents of ALND Level I & II : standard levels of dissection Interpectoral nodes (Rotter s node) Level III only in cases with gross disease in level II More than 10 nodes retrieved by pathologic examinations

17 Complications of ALND Pain, axillary web syndrome Hematoma or seroma Infection Lymphedema : ~30% Shoulder dysfunction Weakness or Numbness Op time, Cost Morbidity

18 Sentinel Lymph Node Biopsy

19 Historical Background Ramon Cabanas used term of sentinel node on penile cancer

20 Lymphatic drainage of breast 76~95% 1.3~9.9% Sappey s subareolar plexus (1874 년 ) Ann Surg Oncol 2008;(3):

21 Sentinel Lymph Node

22 Immunohistochemistry for Cytokeratin

23 Sentinel lymph node The first LN in the chain of nodes that forms the regional lymphatic system A key indicator of axillary metastasis in breast cancer Can be identified using radioactive colloids with or without blue dye (lymphatic mapping) Radioactive colloid Entrapped within the SLN through A function of their particular size Phagocytosis by leukocyte Between 2 and 24 h before surgery Localization of nano-colloid in the SLNs Vital dye Bind to interstitial albumin, and taken up by local lymphatic tissue Lymphatics are converted to bright blue channel Intraoperative injection Directs to the lymphatics that tract to the SLNs

24 Lymphatic mapping Injection site Intradermal, Subdermal, Subareolar, Peritumoral, Intratumoral

25 Lymphatic mapping Radioisotope with lymphoscintigraphy Technetium 99-labeled sulfur colloids

26 Lymphatic mapping Radioisotope with lymphoscintigraphy Detected by gamma probe 10% rule Removal of all SLNs with counts over 10% of the most radioactive node (hot nodes)

27 Isosulfan blue Lymphatic mapping Vital blue dye Albumin 과결합하여선택적으로림프관을따라이동 림프관및감시림프절을파랗게염색시킴. Methylene blue, Indigo carmine, patent blue V, Indigo cyanine green

28 Lymphatic mapping Vital blue dye Massage

29 Complication of Vital dye Anaphylaxis False hypoxia Skin stain

30 Double method Vital dye + Radioisotope Detection rate False negative

31 Effect of the number of SLN removed

32 Advantages of SLNB Compared to ALND, Less infection Less lymphedema Less shoulder dysfunction Less weakness, pain Not inferior accuracy for staging

33 ASCO guideline in 2005 Lyman, et al. J Clin Oncol 2005;23:

34 ASCO guideline updates in 2014 권고안 1. 조기유방암환자에서감시림프절전이가없을경우액와림프절곽청술을권고해서는안된다. 권고안 2.1 유방보존술후전유방방사선치료가예정되어있으면서, 1~2 개의감시림프절전이가발견된조기유방암환자의경우액와림프절곽청술을권고해서는안된다. 권고안 2.2 유방전절제술이계획된조기유방암환자에서감시림프절전이가발견된경우액와림프절곽청술을제안해도된다. 권고안 3. 아래와같은상황에있는수술이가능한유방암환자의경우감시림프절생검술을제안해도된다. 3.1 Multicentric tumors 3.2 유방전절제술이필요한상피내암 3.3 이전에유방이나액와부에수술을시행했던경우 3.4 수술전항암화학요법을시행한경우 권고안 4. 아래와같은상황에있는조기유방암환자에서감시림프절을시행해서는안된다고규정한 2005 년도권고안을바꿀만한충분한근거는아직없다. 4.1 종양이크거나국소진행성유방암의경우 (Tumor size T3/T4) 4.2 염증성유방암 4.3 유방보존술이예정된상피내암 4.4 임신의경우

35 ACOSOG Z0011 Primary Objective -> To assess whether OS after SLND alone was not inferior to that for patients who underwent completion ALND for a positive SLN

36 Z0011 eligibility Eligible Clinical T1-2N0 breast cancer H&E-detected SLN metastases Lumpectomy + Whole breast RT Adjuvant systemic Tx by choice Ineligible Nodal RT IHC-detected SLN metastases Matted nodes 3 or more involved SN Giuliano AE et.al. Ann Surg 2010;252:439

37 Z0011 locoregional recurrence Recurrence SLN+ ALND (n=388) SLN+ no ALND (n=425) local 3.6% 1.9% regional node 0.5% 0.9% local+regional 4.1% 2.8% Additional positive nodes in 27% of ALND s P = 0.47 Giuliano AE et.al. Ann Surg 2010;252:439

38 Z0011 overall survival Giuliano AE et.al. JAMA 2011;305:569-75

39 NCCN guideline 2016 Surgical axillary staging

40 감사합니다.